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Purpose: Antimicrobial misuse contributes to antimicrobial resistance in thoracic transplant (TTx) and mechanical circulatory support (MCS) recipients. This study uses a modified Delphi method to define the expected appropriate antimicrobial prescribing for the common clinical scenarios encountered in TTx and MCS recipients. Methods: An online questionnaire on managing 10 common infectious disease syndromes was submitted to a multidisciplinary Delphi panel of 25 experts from various disciplines. Consensus was predefined as 80% agreement for each question. Questions where consensus was not achieved were discussed during live virtual live sessions adapted by an independent process expert. Results: An online survey of 62 questions related to 10 infectious disease syndromes was submitted to the Delphi panel. In the first round of the online questionnaire, consensus on antimicrobial management was reached by 6.5% (4/62). In Round 2 online live discussion, the remaining 58 questions were discussed among the Delphi Panel members using a virtual meeting platform. Consensus was reached among 62% (36/58) of questions. Agreement was not reached regarding the antimicrobial management of the following six clinical syndromes: (1) Burkholderia cepacia pneumonia (duration of therapy); (2) Mycobacterium abscessus (intra‐operative antimicrobials); (3) invasive aspergillosis (treatment of culture‐negative but positive BAL galactomannan) (duration of therapy); (4) respiratory syncytial virus (duration of antiviral therapy); (5) left ventricular assist device deep infection (initial empirical antimicrobial coverage) and (6) CMV (duration of secondary prophylaxis). Conclusion: This Delphi panel developed consensus‐based recommendations for 10 infectious clinical syndromes seen in TTx and MCS recipients. [ABSTRACT FROM AUTHOR]

Donor‐derived infections in solid organ transplantation can be prevented by risk stratification of donors based on available information, and inquiries surrounding possible or diagnosed infection are common questions posed to transplant infectious disease subspecialists. This article outlines the five key steps in addressing a donor call from a transplant team in a systematic approach, focusing on donor and recipient‐specific factors, transmissibility and treatment of possible infections, and the likelihood of a patient's future organ offers and mortality remaining on the waitlist. These principles are then applied to five donor call cases, in which we review the key takeaway points and supporting literature. These cases can be used as a resource for teaching with trainees. [ABSTRACT FROM AUTHOR]

There is an ongoing need to understand whether transplantation during acute Coronavirus disease 2019 (COVID‐19) can be performed safely, especially when urgent transplant is required. We collected retrospective data of all consecutive non‐lung transplant recipients who had a positive SARS‐CoV‐2 polymerase chain reaction (PCR) on the day of planned deceased donor organ implantation. Data were collected from two large transplant centers from 01/01/2022 to 02/01/2023. Demographics, details regarding COVID‐19 infection, waitlist priority, and details regarding transplantation were obtained. A descriptive analysis was performed. A total of 12 patients were identified: 7 renal, 4 liver, and 1 heart transplant recipient. All 12 patients were vaccinated for COVID‐19. Ten were asymptomatic outpatients found positive on admission and transplanted immediately. Two were in‐patients with mild COVID‐19 symptoms and were reactivated on the waitlist following 3 days of remdesivir when no progression to severe COVID‐19 occurred. Most patients (10/12) received remdesivir posttransplant. No complications attributed to COVID‐19 were noted nor were any secondary family or healthcare worker infections observed. All recipients were managed with special isolation precautions befitting their potentially infectious state. Standard induction therapy was used in all recipients. After a median follow up period of 143 days (interquartile range: 96–201 days), 3 episodes of rejection were documented, 2/7 renal recipients experienced delayed graft function, and 2/4 liver recipients required renal replacement therapy. Graft and patient survival were 100%. Transplantation can safely proceed in select, minimally symptomatic, non‐lung recipients with a positive SARS‐CoV‐2 PCR at the time of transplant. [ABSTRACT FROM AUTHOR]

The Organ Procurement and Transplantation Network maintains a data review that is regularly updated as a potential source of additional information.13 We commend transplant centers for sharing their experiences transplanting organs from COVID-positive recipients and urge others to do the same. As the coronavirus disease 2019 (COVID-19) pandemic evolves, transplant centers are successfully exploring avenues to safely utilize organs from donors testing positive for COVID-19. As the SARS-CoV2 virus becomes endemic, donors will continue to test positive for COVID-19, and transplant centers need to understand how to assess these donors and safely utilize these organs. [Extracted from the article]

Mycobacterium tuberculosis can be transmitted via organ donation and result in severe outcomes. To better understand donor‐derived tuberculosis (DDTB), all potential transmissions reported to the Organ Procurement and Transplantation Network (OPTN) Ad Hoc Disease Transmission Advisory Committee between 2008 and 2018 were analyzed. Among 51 total reports, nine (17%) (9 donors/35 recipients) had ≥ 1 recipient with proven/probable disease transmission. Of these, eight were reported due to recipient disease, and one was reported due to a positive donor result. Proven/probable DDTB transmissions were reported in six lung and five nonlung recipients. The median time to diagnosis was 104 days posttransplant (range 0–165 days). Pulmonary TB, extrapulmonary TB, pulmonary plus extrapulmonary TB, and asymptomatic TB infection with positive interferon‐gamma release assay were present in five, three, one, and two recipients, respectively. All recipients received treatment and survived except for one whose death was not attributed to TB. All donors associated with proven/probable DDTB had ≥ 1 TB risk factor. Six were born in a TB‐endemic country, five had traveled to a TB‐endemic country, three had been incarcerated, and three had latent TB infection. These cases highlight the importance of evaluating donors for TB based on risk factors. Early posttransplant TB in organ recipients of donors with TB risk factors requires prompt reporting to OPTN to identify other potential affected recipients and implement timely treatment interventions. [ABSTRACT FROM AUTHOR]

Waitlisted patients in urgent need of an organ, such as patients with end stage heart disease or fulminant liver failure, may be considered for organ transplant from a COVID-19 positive donor. A case report of successful kidney transplantation from a deceased donor with terminal COVID-19-related lung damage: ongoing dilemma between discarding and accepting organs in COVID-19 era! All three recipients developed critical COVID-19 infection, and one died.6 No other cases of donor derived COVID-19 have been reported among other types of solid organ transplant recipients. Already challenged by organ shortages and high waitlist mortality, the field of organ transplantation has suffered considerably from the COVID-19 pandemic. [Extracted from the article]

The Disease Transmission Advisory Committee (DTAC) of the Organ Procurement and Transplantation Network focuses on issues related to the transmission of disease through organ transplantation. Providing a review of potential cases of transmission, translating aggregate data into actionable education and guidance for the transplant community, and providing input for policy development, DTAC aims to improve the safety of organ transplantation through a reduction in donor‐derived transmission events. Through its nearly 20‐year history, DTAC has provided education, guidance, and policy, addressed numerous emerging infections, and continuously focused on the community's understanding of risk assessment related to donor‐derived transmission. By updating the DTAC mission to both decrease transmission and safely expand the donor pool with additional guidance to safely use organs previously not considered for transplantation due to transmission concerns, the Committee's role will remain critical. [ABSTRACT FROM AUTHOR]

ABSTRACT Background Methods Results Conclusions Belatacept is a costimulatory blocker that can be used to prevent and treat rejection in lung transplant recipients (LuTRs). The epidemiology of infections in belatacept‐treated LuTRs has not been systematically evaluated.We performed a single‐center retrospective study of all adult LuTRs who received belatacept as prevention or treatment of antibody‐mediated rejection (desensitization) or as part of maintenance immunosuppression from January 1, 2011, to June 30, 2022. We assessed the epidemiology of infections that occurred within 12 months following the first belatacept dose.Fifty‐two LuTRs received at least one dose of belatacept as either desensitization (n = 32) or maintenance immunosuppression (n = 20). Among 45 patients who were cytomegalovirus (CMV) donor and/or recipient seropositive, nine (20%) developed CMV infection. Seven (77%) CMV infections occurred despite valganciclovir prophylaxis and four (44%) were associated with antiviral resistance. Three (6%) LuTRs developed Epstein‐Barr virus (EBV) associated post‐transplant lymphoproliferative disorder (PTLD). Twenty‐five (48%) LuTRs developed 43 bacterial infections and five (10%) developed proven or probable invasive fungal disease. Incidence rates of viral, bacterial, and fungal infections were similar between the desensitization and maintenance groups: incidence rate ratios (95% confidence interval) were 0.70 (0.32–1.57), 1.31 (0.70–2.46), and 2.82 (0.31–25.2), respectively. Infection/PTLD prompted belatacept discontinuation in eight (15%) patients.In the first year after belatacept initiation, LuTRs commonly developed CMV infections, EBV+ PTLD, and bacterial infections. Multicenter collaborations are needed to better understand infection risks in LuTRs treated with belatacept. [ABSTRACT FROM AUTHOR]

These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation will review the current state of the art of donor‐derived infections. Specifically, the guideline will summarize standardized definitions and approaches to defining imputability, updated data on the epidemiology of donor‐derived infections, and approaches to risk mitigation against transmission of infections. This update will additionally provide guidance on the use of HIV+ donors in HIV+ recipients, the use of HCV‐viremic donors in non‐viremic recipients, donors with endemic infections, and donors with bacteremia, meningitis, and encephalitis. Lastly, the guidance will summarize an approach to recipients with a suspected donor‐derived infection. [ABSTRACT FROM AUTHOR]

Historically, potential lung donors who have detectable antibodies to hepatitis C virus have been declined by most centers due to concern for possible disease transmission. We sought to evaluate hepatitis C viral transmission rates from donors who were known to be HCV Ab positive but HCV NAT negative. We performed a single‐center retrospective review of a prospectively collected database for lung transplant recipients at our center including HCV Ab+NAT‐ donors (approved January 2017). Donor and recipient demographic data were compiled, and records were queried to ascertain rate of seroconversion. During the study period (1/1/17 to 8/9/17), a total of 64 recipients underwent lung transplantation. Thirteen (20%) donors were HCV Ab+NAT‐. All recipients of HCV Ab+NAT‐ grafts were HCV Ab‐ at the time of transplant. Recipients of grafts from HCV Ab+NAT‐ donors underwent protocol NAT at 2 and 12 months and all are NAT‐ to date. One recipient developed reactive HCV Ab at 6 months post‐transplant. Follow‐up NAT showed HCV RNA to be undetectable. To date, use of HCV Ab+NAT‐ donors in lung transplantation has yielded favorable outcomes, with evidence of one transient seroconversion suggesting this practice may increase access to life‐saving transplantation to those in need. [ABSTRACT FROM AUTHOR]

Invasive mold disease in thoracic organ transplant recipients is a well‐recognized complication, but the long‐term persistence of molds within the human body and evasion of host defenses has not been well‐described. We present 2 cases of invasive mold disease (Verruconis gallopava and Aspergillus fumigatus) in thoracic transplant recipients who had the same mold cultured years prior to the invasive disease presentation. The paired isolates from the index and recurrent infections in both patients were compared using whole‐genome sequencing to determine if the same strain of mold caused both the index and recurrent infections. In Case 1, the isolates were found to be of the same strain indicating that the initial colonizing isolate identified pre‐transplant eventually caused invasive mold disease post‐transplant while in Case 2, the 2 isolates were not of the same strain. These results demonstrate the distinct possibility of molds both persisting within the human body for years prior to invasive mold disease or the long‐term risk of recurrent, persistent infection with more than one strain. Further studies of long‐term molecular epidemiology of IMD and risk factors for mold persistence in transplant recipients are encouraged. [ABSTRACT FROM AUTHOR]

The opioid epidemic has resulted in a potential increase in donors in the testing window period for hepatitis C virus (HCV). We analyzed HCV reports to the Disease Transmission Advisory Committee (DTAC) between 2008 and 2016 to estimate the risk of HCV transmission. In 15 of 95 (16%) reports, at least one recipient developed proven/probable donor‐derived HCV resulting in 32 infected recipients. Seven transmissions occurred during the nucleic acid testing (NAT) window period; four occurred during serological window period. The other four transmission occurred due to human error (3) and false‐negative serology (1). All seronegative‐exposed liver and lung recipients contracted HCV; 18/21 (86%) kidney and 3/4 (75%) heart recipients developed HCV. Four transmitting donors died of intravenous drug overdose, three in 2016 and one in 2012. Among donors with a history of intravenous drug use (IVDU), drug intoxication as a mechanism of death, or increased risk status, and negative screening HCV testing, the risk of transmission to a recipient was about 1 in 1000. The overall risk of transmitting HCV from NAT‐negative donors with IVDU is low and consistent with modeling data. This information may be helpful to clinicians counseling potential recipients offered these organs. [ABSTRACT FROM AUTHOR]